Scaling Village Health Leader–Led Community Maternal and Newborn Health Interventions in Underserved Ethiopian Communities: Evidence on Effectiveness, Safety, and Implementation

Abstract Introduction : Women in remote agrarian and pastoralist populations in Ethiopia face substantial barriers to accessing timely, quality facility-based maternal and newborn health (MNH) services, contributing to persistently high rates of home births and preventable maternal and neonatal deaths. Community-based delivery strategies that extend high-impact interventions into underserved communities have shown promise in improving care practices and outcomes. This study assessed the effectiveness and safety of community-based MNH interventions delivered by trained Village Health Leaders (VHLs) in Ethiopia’s agrarian and pastoralist settings. Methods : The project implemented and tested a scalable VHL-led community-based delivery model of life-saving MNH interventions, including advance distribution of iron and folic acid supplements, misoprostol, chlorhexidine, and progestin-only pills. We conducted an embedded implementation research study using a quasi-experimental, controlled before-and-after household survey design. Data were drawn from 4,017 mothers of children aged 0–11 months (1,631 intervention; 2,386 comparison). A two-stage cluster sampling approach was used to identify eligible households across 25 intervention and 54 comparison kebeles. Baseline data were collected in August–September 2023 and end-line data in June–September 2025. To estimate causal effects while accounting for non-random program placement and baseline differences, we employed a propensity score–matched difference-in-differences (PSM-DiD) approach. Propensity scores were estimated using logistic regression with separate models for agrarian and pastoralist contexts. Results : Misoprostol was used correctly by more than 97% of women who delivered at home, with only minor side effects and no reported adverse maternal or neonatal events. Facility delivery increased significantly in intervention areas. In agrarian settings, it increased from 19.2% at baseline to 26.5% at end line (+ 7.6%), while it declined in comparison areas (–7.5%; OR 2.4, p < 0.001). In pastoralist settings, facility delivery increased from 11.7% to 25.2% (+ 13.5%), compared with a + 5.1% increase in comparison areas (OR 1.8, p = 0.027). Suspected postpartum hemorrhage significantly declined in agrarian intervention areas (from 3.5% to 0.5%) but increased in comparison areas. Coverage of key maternal health indicators improved across both contexts, including at least one ANC contact and four or more ANC visits. Uptake of iron-folic acid supplementation increased significantly in agrarian (Did + 13.5, p < 0.001) and pastoralist (DiD + 7.2, p = 0.016) populations. Delayed newborn bathing after 24 hours rose substantially in intervention areas (agrarian + 26.4%, pastoralist + 28.2%; both p < 0.001). Adoption of postpartum family planning improved significantly in agrarian intervention areas, contrasting with declines in comparison areas (OR 3.5, p < 0.01). Conclusions : VHL-led community delivery of MNH interventions was feasible, acceptable, safe, and effective, significantly increasing the uptake of evidence-based care practices and reducing preventable risks in underserved communities. This study provides further evidence that addresses and clarifies common concerns about the safety of community-level distribution of misoprostol and other essential MNH comodities. To maximize impact and equity, policymakers should prioritize the institutionalization and scale-up of VHL-led community MNH interventions within the primary health care framework.